Provider Demographics
NPI:1528443819
Name:BOULTER, STEPHANIE (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BOULTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ANDERSON ST
Mailing Address - Street 2:APT 244
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15212-5818
Mailing Address - Country:US
Mailing Address - Phone:240-447-9984
Mailing Address - Fax:
Practice Address - Street 1:2000 GLEN ECHO RD STE 111
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2857
Practice Address - Country:US
Practice Address - Phone:615-657-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA3636363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant